The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 388 Results

An exploratory analysis of the association between hospital quality measures and financial performance.

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Beauvais B, Dolezel D, Ramamonjiarivelo Z. Healthcare (Basel). 2023;11:2758.

Patient safety improvement efforts involve financial expenditures, which means that hospital leaders must evaluate their return on investment. This study examines the association of several quality-of-care measures and hospital profitability as measured by patient revenue per adjusted discharge. Better patient satisfaction, lower readmission rates, and three of the four Hospital Value-Based Purchasing Program (HVBP) domains were associated with improved financial outcomes.

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

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Maxwell A. Washington DC: Office of Inspector General; September 2023. Report no. OEI-05-22-00290.

Falls are a persistent threat to patient safety and effective reporting of this adverse event can assist in understanding important gaps in care. This report examines the incidence of Medicare home health patients experiencing falls with major injury resulting in hospitalization that were not reported as required. 55% of falls were not documented thusly negatively impacting the viability of Care Compare as a reliable public resource for this information.

Adverse Events.

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United States Office of the Inspector General: 2010-2023.

Large-scale data analysis provides insights to generate evidence-based improvement action. This collection of reports provides access to investigations of the impact of healthcare-related harm events in Department of Health and Human Services (HHS) programs and across the United States health system. This set of publications not only examines weaknesses but provides recommendations for improvement on topics such as gaps in fall reporting by home health agencies, Medicare adverse events and the viability of payment incentives as a strategy for medical harm reduction.

Robert L. Wears Patient Safety Leadership Award.

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Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL.

Inspired by the research and leadership of Dr. Robert Wears, this award annually recognizes individuals, teams or organizations that examine the applications of safety science concepts to improve medicine. Nominations for the 2024 award must be submitted by January 2, 2024.

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.

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Bremner BT, Heneghan CJ, Aronson JK, et al. J Patient Saf Risk Manag. 2023;28:227-236.

Autopsies and coronial investigations provide important learning opportunities. In the UK, coroners may issue Prevention of Future Death reports (PFD) when they determine taking actions could prevent future deaths. This review summarizes studies that use PFDs to investigate patient safety, such as medication- or diagnosis-related deaths. The authors conclude the impact of PFDs could be strengthened by improving the reporting and dissemination system and enforcing the requirement that hospitals submit a response.

The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.

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Ali KJ, Goeschel CA, DeLia DM, et al. Diagnosis (Berl). 2023;Epub Oct 5.

To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

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Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.

Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

DAISY Award for Extraordinary Nurses in Patient Safety.

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The Daisy Foundation and Institute for Healthcare Improvement.

Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This award recognizes nurses that exhibit compassion, patient and family centeredness, and a commitment to workplace safety. The award will be presented at the annual IHI Patient Safety Congress. The award nomination process for 2023 closes on December 3.

A Transformational Effort on Patient Safety.

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Subgroup on Patient Safety. Washington DC: President’s Council of Advisors on Science and Technology; September 2023.

The President’s Council of Advisors on Science and Technology brings together topic experts to summarize important issues for the consideration of the President of the United States. This report introduces the persistent problem of unsafe care and recommends a federal leadership entity, application of evidence-based solutions, true patient partnership and research funding as avenues to achieve stable improvement.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

Mark Graber Diagnostic Quality & Safety Award.

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Society to Improve Diagnosis in Medicine.

Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The deadline to submit a 2023 nomination is September 12, 2023.

2022 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2023;49(9):435-450.

The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his passing. This special issue highlights the efforts of the 2022 Eisenberg Award honorees and their impact on improving patient safety and quality. The 2022 award recipients coved here include Jason S. Adelman, MD, MS, and North American Partners in Anesthesia (NAPA).

Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.

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Fu BQ, Zhong CCW, Wong CHL, et al. Int J Health Policy Manag. 2023;12:7089.

Peri-discharge interventions aim to reduce potential adverse events that can arise during and after hospital discharge. This systematic review of 13 qualitative studies identified common barriers and facilitators to implementing peri-discharge interventions. Frequently cited barriers included limited resources, poor team communication, and complicated intervention processes; common facilitators included leadership support, a positive organizational culture, and financial penalties.

Value assessment of deprescribing interventions: suggestions for improvement.

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Hung A, Wang J, Moriarty F, et al. J Am Geriatr Soc. 2023;71:2023-2027.

Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.

Accuracy of infection reporting in US nursing home ratings.

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Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.

Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.

John M. Eisenberg Patient Safety and Quality Award.

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Joint Commission, National Quality Forum.

The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application process. The 2023 award submission cycle is open through August 21, 2023.

American Hospital Association–McKesson Quest for Quality Prize.

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American Hospital Association.

This award program recognizes organization-wide commitment to five key goals that support high-quality health care: access, health, innovation, affordability, individual as partner. The deadline for submitting an application for the 2024 award cycle has passed.

Leape Ahead Award.

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American Association for Physician Leadership.

Efforts to incorporate respect and patient safety concepts into medical training have been inspired by the work and leadership of Dr. Lucian Leape, founding chairman of the Lucian Leape Institute. This annual award was established to recognize individuals and organizations that focus on developing medical student and resident skills in quality and safety improvement. The 2023 application process is now closed.

Challenge Competition: Impact of Patient Safety Tools.

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Agency for Healthcare Research and Quality, Rockville, MD. 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study.

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Kirwan G, O’Leary A, Walsh C, et al. Eur J Hosp Pharm. 2023;30:86-91.

Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.

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